Research and Reality: Using Mobile Messages to Promote Maternal Health in Rural India
Divya RamachandranUniversity of California, Berkeley
Vivek GoswamiDhirubhai Ambani Institute of ICT
John CannyUniversity of California, Berkeley
20% of global maternal deaths each year occur in India
Global Maternal Mortality
[www.worldmapper.org]
Village Health Workers
Accredited Social Health Activists (ASHAs) monitor and provide services for pregnant and postnatal women
Anganwadi Workers (AWWs) monitor the growth and cognitive development of children 0-5 years of age
Challenges• Poor training programs• Limited education/literacy• Issues in credibility• Traditional beliefs and barriers [Ramachandran et al., CHI 2010]
Iterative Design of Mobile Videos
OnOn--thethe--job reference materials to increase discussion between job reference materials to increase discussion between health workers and clients.health workers and clients.
Video Example
Video on danger signs during pregnancy created by researcher with the help of a local artist and NGO staff.
Mobile videos served as on-the-job training materials for health workers, increasing both knowledge and self-efficacy.
However, health workers had to be trained extensively on how to pause and discuss the videos to ensure their clients understood.
Designing Persuasive Messages“Pregnant women often have swollen feet. They should feel better if you stretch and put them up for a few minutes two or three times a day, and drink a lot of water. But, if your feet are severely swollen when you wake up in the morning, or if you see that your hands and face are also swollen, this could be a sign of a very serious problem called pre-eclampsia.”
1. Start with existing practices/beliefs, i.e. relevant myths and barriers to increase familiarity
2. Takeaway should always be some action to be performed
3. Message should be broken into short, discussable segment• Move from lecture-based to dialogic style
Persuasive Message Architecture
Lecture Example
Myth GeneralStatement
Many women believe that <myth>.
Correction Explanation <myth> is not true; in fact, <correction>.
Action Instruction You should <action>.
Dialogic Example
Question about personal beliefs
Do you believe that <myth>?
Explanation with rhetorical question tags
<myth> is not true; in fact, <correction>, did you know that?
Request for personal commitment
Will you <action>?
Common myth: iron tablets will make the baby too big to deliver normally
1. Start with existing practices/beliefs, i.e. relevant myths and barriers to increase familiarity
2. Takeaway should always be some action to be performed3. Message should be broken into short, discussable segments
Application DesignBuilt J2ME application that plays customizable
content in lecture and dialogic stylesDialogic waits for button press after each question
Added support for two languages, Oriya and KuiHealth workers and clients often did not speak same
language!
Take iron tablets to prevent anemia
Save money in case of an emergency during birth
Study Design• Recruited 7 health workers and 52
of their clients
• Two house visits to each client, with health worker– Counseling session (between 15-30
minutes)– Follow-up after 7 days without prior
notice to count number of iron pills taken and amount of money saved.
Lecture LA LB
Dialogic DA DB
Control (no phone)
CA CB
Lecture Style Video
Dialogic style video
Results: Quality of Counseling
0
50
100
150
200
250
300
350
Dialogic Lecture
Pause Length (s)
00.5
11.5
22.5
33.5
44.5
Dialogic Lecture
Health Worker Activity
Quality of counseling significantly improved with dialogic style of message presentation.
(p < 0.001) (p < 0.001)
Quality of counseling sessionpause time during video (for discussion and explanation)activity of health worker
Results: Client Engagement
0
0.5
1
1.5
2
2.5
3
Dialogic Lecture
Response to Phone
0
0.5
1
1.5
2
2.5
3
3.5
4
Dialogic Lecture
Response to Health Worker
0
0.5
1
1.5
2
2.5
3
Dialogic Lecture
AlertnessEngagement of client
Response by client to videoResponse by client to health workerClient attention
No apparent increase in clientengagement
(p = 0.16) (p = 0.16)
(p = 0.12)
Results: Persuasive Power
Most women took iron tablets80% of participants did not have iron pills a priori (we provided them: another intervention)Personal attention from health worker (and us) was rare
Most women could not save moneyMoney-saving depended on whether they could find coins to save
0
1
2
3
4
5
6
7
Dialogic Lecture Control
Iron Pills Taken
0
1
2
3
4
5
6
7
8
Dialogic Lecture Control
Amount of Money Saved(p = 0.86) (p = 0.61)
Research and Reality• Iterative design
– application– health content– research study
• Priority– methodological rigor or preservation of contextual
realities?• Changes and compromises
– research goals were impacted by real challenging factors in the environment
Truly Rural
Fewer participantsFewer participantsMore confoundsMore confoundsHigher variabilityHigher variability
Cutting Across Castes
Health workers ofHealth workers of the same caste as clients were the same caste as clients were significantly more persuasive (p < 0.01)significantly more persuasive (p < 0.01)
Unidentified Foreign Researchers• Enforced a new practice
– House visit conducted– Health messages delivered– Iron tablets received
• Influenced credibility of the message“She has come from so far to deliver this message to you – it must be important then, right?”
• Motivated health workers“You woke up in the middle of the night to get here this early, of course I’ll make time to visit a few houses with you!”
Research Study, or Intervention?• Goal was to run an in-context study for evaluation, but
the study changed the context!– 100% of women received iron tablets, not 20%– Health workers and clients met and talked for the first time– Phones caused a stir
• How do we isolate the effects of the technology? Do we need to?
• Would an intervention have been different ?
• The success of ICTD interventions often depends on other factors which are natural counterparts.
More than thirty women started taking iron More than thirty women started taking iron tablets and saving money for birth emergenciestablets and saving money for birth emergencies..
Questions?Questions?Thoughts?Thoughts?Comments?Comments?
